# Johnson & Higgins BIS Financial Source Document

**Document Number:** [Blank]
**Office Number:** 001
**Office Name:** New York
**Prepared By:** [Handwritten Name]
**Dept.:** Casualty
**Authorized By:** [Handwritten Name]
**Date:** 7/16/87

**Function:**
- [ ] FROM & TO (A,B)
- [ ] BOUNCED CHECK (B)
- [ ] DIRECT PAYMENT (B)
- [ ] CLAIMS (B)
- [ ] INCOME & PAYABLE (B)
- [ ] PAYEE CHANGE (A,B)
- [ ] DIRECT PAYMENT-COMM ONLY (B)
- [ ] INCOME SHARE ADJUSTMENT (B)

**FROM & TO OPTIONS:**
- [ ] A/R CASH
- [ ] A/R CREDIT
- [ ] A/P ON ACCT
- [ ] A/R
- [ ] A/P
- [ ] INCOME

**AS:**
- [ ] ON ACCOUNT
- [ ] INVOICE PAYMENT
- [ ] COUNTERSIGNATURE FEE
- [ ] FINDERS FEE
- [ ] REVERSE FINDERS FEE
- [ ] MISC. INCOME
- [ ] COMM. RECEIPT BILLED
- [ ] PAYABLE RECEIPT
- [ ] DIRECT BILL

**Box A:**
- **Client No.:** [Blank]
- **Invoice No.:** [Blank]
- **Invoice Item No.:** [Blank]
- **Share Item No.:** [Blank]
- **Payee No.:** [Blank]
- **A/P Type:** [Blank]
- **Tax Code:** [Blank]

**Box B:**
- **Amount:** 1,674,973
- **Client No.:** 2205500000
- **Invoice No.:** 220943
- **Invoice Item No.:** 004
- **Payee No.:** 1515E
- **Reason Code:** [Blank]
- **Comm. Share:** [Blank]
- **Dept. No.:** 2010
- **A/P Type:** [Blank]
- **Currency Rate:** [Blank]
- **Currency Co.:** [Blank]
- **Tax Code:** [Blank]
- **Underwriter:** 15106
- **Attachment Date:** 05/21/87
- **Expiration Date:** 05/21/88
- **Prod L/POL T:** 40
- **POL Verify:** [Blank]
- **Policy Status:** [Blank]
- **Function:** [Blank]
- **Policy No.:** 6637869803
- **Income:** [Blank]
- **Premium:** 1,01047100
- **Net Prem:** [Blank]
- **Tax Amount:** [Blank]
- **Share Amount:** [Blank]
- **Share Dept.:** [Blank]